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For practical reasons, the content of this section has been divided into several “articles”, grouped by topic: the first topic is on scientific aspects, the second on ethical aspects. Finally, we report some further contents for in-depth analysis.

Here below you can find all the bibliographical references quoted and progressively numbered within the different articles. Enjoy the reading!

Scientific aspects (*)

(*) We thank professor William B. Carey, a Medicine graduate and Clinical Professor of Pediatrics at the School of Medicine of the University of Pennsylvania, Director of the Behavioral Pediatrics/General Pediatrics Department at the Pediatric Hospital of Philadelphia, for his precious contribution.

A further throughout report on ADHD

Scientific Aspects

A few notes on science and its condition in contemporary society.

Science is the codification, on a theoretical level, of discoveries obtained through the application of the scientific method. Such method requires the following steps: observation, hypothesis, prediction, experimentation, validation or invalidation of the hypothesis, thesis. Moreover, characteristic traits of the scientific methodology are prudence, doubt and the consideration that every discovery is, in any case, relative, and will soon or late be outdated by new knowledge, from which it derives a modest and relativistic approach in relating to the knowledge gained. Subjectivity, judgment or personal opinions are therefore always excluded from the scientific approach.

Undoubtedly, there exist truths which every person has adopted as his/her own, and in which he/she believes, out of choice or faith: such orientations belong to the political, philosophical, religious spheres and so forth, and have nothing to do with science.

The scientific course and methodology allowed us to gain a knowledge, and to derive its applications, from which each of us benefits. This scientific knowledge has pushed on towards such a broad variety of directions, that nobody can afford to grasp in toto a detailed cognition of it: the degree of knowledge referring to each single topic has reached such a limit that specialization is absolutely necessary for in-depth study and research. In practice, this factor caused the maintenance of a knowledge gap between the scientist and the common citizen, but not only: in many cases, it led to a partial isolation of scientists within their respective fields of application and study.

We too frequently assisted to enthusiastic announcements, even uttered by influential scientists, regarding scientific discoveries presented as such, while actually being just simple hypotheses, completely unproven by experimentation. The massive economic interests, in addition to the hunger for fame and possible personal interests often revolving around the scientific field, have certainly contributed, in those cases, to the distortion of the truth and of evidence.

We reached the point that, in the course of 2000, the staff of three among the most influential international scientific reviews (“Science”, “Lancet” and “Nature”) published an editorial to inform that, when necessary and especially in case of articles that actually celebrate the efficacy of on-the-market pharmaceutical products, a footnote will be affixed to specify that, with regards to such articles, the review cannot assume full responsibility for the truthfulness of presented data, which instead belongs to the authors [1].

In this situation, some researchers can find themselves in the condition of providing answers or uttering statements that their interlocutors are unable to contest, and that are often accepted as absolute truths. Moreover, the control mechanisms and the scientific debate frequently remain confined within the own academic world of each specific sector; practically, a group judges itself and its members.

Medical and medical semiotics reference, pertinent to our issue.

Medicine aims at curing – and if possible, at healing – diseases, as well as at relieving the pain of those suffering from such diseases.

The De Voto Oli Dictionary of Italian Language defines the word “disease” as “an abnormal condition of the organism, caused by organic or functional alterations of evolutive trend towards death, recovery or a new, different life condition”.

Each and every disease is clearly identifiable through specific exams capable of detecting anomalies in the body, organ, tissue or cell: on the basis of neither a subjective opinion, nor tests that need to be “interpreted”.

Medical pathology is a fundamental branch of medicine. Pathologists are in charge of identifying and classifying all possible anomalies and also, in the more specific sector of forensic pathology, the causes of death. In the most renown pathology textbooks, the word “disease” is defined as an “an abnormality in the structure or function of cells, tissues, organs or organisms”.

Every possible disease, from the most severe to the most harmless, is visible and measurable through the alterations it provokes within cells, tissues, organs or their metabolism. In addition to this kind of disease, possible anomalies at the molecular level can cause alterations to the correct bodily functioning, as precisely defined by “molecular” biology.

From cancer to a cold, medicine possesses objective tests (machinery, lab tests, radiographers and other verification devices) which can prove or disprove the presence of every disease, regardless of any operator’s subjective opinion. Personal opinions and ideas do not matter within medicine: this is what makes medicine a science.

We can further illustrate the scientific methodology in the field of medicine.

Medical semiotics teaches to distinguish between symptoms and signs [2].

A symptom is what the patient voluntarily says, states or does. Symptoms are subjective sensations, such as complaining over pain or referring a feeling of heartburn. Symptoms are important, they help address the clinical investigation; but as we well know, symptoms are absolutely never considered sufficient to provide a diagnosis: they can deceive. A person can enter the emergency room complaining over a terrible stomach pain, but an examination could reveal an acute pancreatitis that has nothing to do with the stomach. Similarly to police investigations, symptoms are therefore simple clues, they are not evidence allowing us to find the offender.

Then we have the signs. They do not belong to the patient’s statements or complains: they are objective confirmations ascertained by the doctor, like a swelled liver, an anomalous cardiac noise, a facial paralysis or a bloodstained expectoration. Remembering our comparison with police investigations, signs are evidence.

Further evidence can derive from lab tests (blood, urine tests and so forth) and from instrumental diagnostics (radiological controls, echographies, dopplers, myographies, magnetic resonances and so forth). A diagnosis is finalized when, and only when, evidence is sufficient and converges unequivocally.

Therefore, once again, we can see how medicine relies on evaluations that are unbiased – or objective, as professor Dioguardi prefers to call them, on tangible evidence: we are in the field of science.

The ADHD (Attention deficit hyperactivity disorder) diagnosis.

Unless one chooses to exhume the works by Rudin and Erlenmeyer-Kimling on the “minimal brain dysfunction” (see the Ethical Aspects), there is no trace of this alleged pathology in medical history; that is, there are no people who ever complained of its symptomatology, interpreting it as “pathological”, contrarily to what can be stated regarding the case of tuberculosis, plague, gastric ulcer or any other pathology of organic nature.

Studying the biographies of renown and notable persons (from Andersen to Beethoven, from Hemingway to Dalì, from Eisenhower to the scientist Steven Hawkins), some scholars have noticed how many of them would have been labeled as suffering from ADHD, had they lived in our times in the US and had they been subjected to tests similar to those currently used for the ADHD diagnosis. Stalin, Mengele and other notorious men were on the contrary absolutely normal kids, if we again adopt the criteria that are currently used for the ADHD diagnosis. When speaking of a pathology which, according to its supporters, may affect a percentage of infantile population ranging from 3% to 20% (!), this appears bizarre, to say the least.

Anthropologists remind us that, within any species, any negative genetic alteration that affects a percentage of over 3% of subjects leads inevitably to the extinction of the species itself. The reason why we are not extinct is thus a mystery. Are we therefore dealing with a positive alteration? Is the ADHD a new pathological entity? The campaign to spread its Word would therefore be a crusade for the salvation of humankind?

ADHD is a diagnosis actually based on the survey of symptoms alone. If medicine proceeded by following the same diagnostic standard, we would reach a paradoxical disease cataloging which would resemble the following scheme (medical diagnosis based on SYMPTOMS):

The utilization of a series of symptoms, substituting a single symptom, clearly does not lead to any further progress from a scientific point of view.

Regardless of our humorous approach, we cannot help underlying that the scope of science is to understand, comprehend; and that this aim requires to differentiate, to find relationships and similarities. The classification of symptomatologic groups does not lead to any defined truth; instead, it may introduce agglomerations of entities that are different by nature, origin and form. There is a risk of grouping, under the expression “ADHD”, phenomena that are completely different from each other by nature and form.

Nowadays, the tests that are utilized for the ADHD diagnosis completely fall within this inconsistent qualitative “standard” (here are some questions, referred to children from two to eight years old):

Lack of attention:

is often unable to pay attention to details, or makes errors due to distraction when doing homework, works or other activities;

presents oft difficulties in focusing on homework or playful activities;

often appears not to listen when directly addressed;

often loses the objects that are necessary for his/her homework or activities (for instance toys, homework assignments, pencils, books and tools);

is often distracted by external stimuli;

is often absent-minded during his/her daily activities.

Hyperactivity:

often moves hands or feet restlessly, or fidgets in the seat;

often leaves his/her seat, in classroom or in other situations where is expected to stay seated;

often runs or jumps all over and excessively, in inappropriate situations;

often “talks too much”.

Impulsivity

often “shoots” an answer before a question is completed;

presents oft difficulties in waiting for his/her turn

often interrupts other people or is intrusive towards them (for instance, meddles with their conversations or games).

(The alleged scientific status of criteria such as “often” and “frequently” is an absolute novelty in medicine).

These tests appear identical to those which occasionally appear on mostly women’s, but also men’s magazines, and which amuse the reader who expresses his/her opinion on a series of closed (yes/no) questions, in order to discover, for instance, if he/she is jealous, shy or “unlucky”; according to the doctors who are the most critical towards the ADHD phenomenon, they also have the same validity. Such “instruments” find their correct classification within the sphere of play and entertaining media communication: rising them to the status of clinical diagnosing instruments risks to appear ridiculous, to say the least. A further cause of concern derives from the tests being administered by teachers, who are often not properly trained.

Nobody wants to deny the existence of children suffering from problems of various nature and kind; surely there are children who display an exaggerated hyperactivity, lack of attention and difficulty in learning, but including them in one and only one nosological category, and stating that these cases are so numerous, risks to result in a marketing operation, since the causes of this phenomenon may be several and various.

Moreover, regarding the enormous number of cases that is propagandized (no less than 3%, or 12%, or 15%, or 20% of children depending on the source!), any doctor or pediatrician, whose career has been even only a few years long, can ask him/herself and honestly answer to the following question: how many cases of this disease actually occurred to me, how many did I visit and cure?

For any further doubt, we believe it appropriate to promote the following considerations.

If ADHD is a real biologic disease, the burden of proof lies on those affirming so.

The proof must consist of:

anatomic-pathological (or biologic-molecular) alterations, relevant in sensitivity and specificity, in the ratio between healthy and diseased population;

clinical-instrumental exams discovering alterations of sufficient sensibility and specificity, in the ratio between healthy and diseased population.

If such proof existed, ADHD would result in a neurological disease, there would be specific biologic tests to confirm diagnoses, and nobody would resort to the utilization of the tests that are currently used for diagnostic purposes, unless a use was possible during the anamnestic phase.

As long as these proofs do not exist, for what concerns the organicity of this phenomenon, we are in the sphere of opinions.

Statements such as those heard so far, like “ADHD is an heterogeneous, complex and multi-factorial disease, of genetic nature in the 80% of cases, and associated to comorbility with other diseases in the 70% of cases” do not modify or add nothing to what so far described. Through the utilization of terms that are unknown to laymen, they may instead impress the public with their priestly style.

An attempt to bolster the scientific status of the ADHD has been made through statements regarding the assent of many influential psychiatrists and some pediatricians; but truth, and least of all scientific truth, derives not from a list of sages, but from scientific proofs in themselves.

A renown American association, the CHAD, significantly financed by the pharmaceutical company Ciba/Novartis (which manufactures the Ritalin, the most sold drug currently on the market for this kind of “therapies”), defines ADHD as a “cerebral disease of biologic origin”. Researches from the National Institute of Mental Health (NIMH, the US study center for these pathologies), including professor Castellanos (who supports the hypothesis of a 100% biological origin of the syndrome) rule over the “National Professional Advisory Committee” (for the coordination of doctors and experts) and approve the CHAD-promoted pronunciation in favor of a “disease” status.

Yet, professor Nasrallah [3] performed a scanning on adult males treated for infantile hyperactivity and concluded that: “…cortical atrophy may be a long-term adverse effect of this treatment”. Therefore, the “deficit” may be caused by the drug utilized for the cures, and not by the alleged “disease” (!). Even if stimulants were administered to all the subject groups treated by Castellanos, researchers – mostly from NIMH – kept on declaring that cerebral atrophy was a proof of ADHD being a disease, avoiding studies on drug-free groups of children. In 1996 Castellanos [4] declared that: “A replication study with stimulant-naïve boys with ADHD is under way”. Such a study never appeared, and therefore, up till now, it is impossible to precisely know if the reported dysfunctions are caused by some pathology or by the drug used for the “cure” itself.

At the 1998 Consensus Conference, always quoted as an “indisputabile source” by the sponsors of the pharmacological solutions, Dr. Swanson (host) and Castellanos [5] summarized how “…recent investigations provide converging evidence that a refined phenotype of ADHD/HKD is characterized by reduced size in specific neuroanatomical regions…”

Professor Baughman (a renowned international expert on the subject) asked: “Dr. Swanson, why didn’t you mention that virtually all of the ADHD subjects in the neuroimaging studies have been on chronic stimulant therapy, and that this is the likely cause of their brain atrophy …?”. [6] Swanson replied: “… this is a critical issue… I am planning a study to investigate that “. Again, such study was never carried out.

Even the final declaration by the Consensus Conference Commission [7] reports: “…there is no independent valid test for ADHD. Although research has suggested a central nervous system basis for ADHD, further research is necessary to firmly establish ADHD as a brain disorder…”.

behavioral problems (insomnia, breakdowns and collapses due to activities and irritability; in some cases, accentuation of the ADHD symptoms themselves). Moreover, variations in the behavior of children, subjected to a therapy with these psychotropic drugs, have been observed with a frequency which is not statistically negligible;

compulsive, obsessive and repetitive persistence in actions that are often meaningless; mental rigidity, loss of elastic thought, fixed ideas, inability to focus correctly;

tendency to solitary behaviors and social isolation, reduction of communication and socialization skills, tendency to avoid responsibilities (it is always “somebody else’s fault”), inability to play with a group;

inability to express emotions, including smiles or signs of depression, sad appearance, frequent bursts of tears;

loss of initiative in actions and relationships, loss of spontaneity, loss of curiosity and of the capability of perceiving sensations such as astonishment and pleasure.

In the following articles, the answer to some questions is provided from the scientific publication “ADHD, Attention Deficit Disorder with Hyperactivity: the unresolved questions” by William B. Carey, professor of Clinical Pediatrics at the University of Pennsylvania, an expert on variations in infantile behavior.

ADHD behaviors or ordinary temperamental variations?

The DSM-IV criteria for ADHD, and the literature of reference, define the inattentive and hyperactive behaviors as abnormal and differing from standards, using the number of symptoms as a key element. If the child displays six, out of nine, symptoms of hyperactivity/impulsiveness, the child diagnosed with ADHD. For both the categories of symptoms, these are labeled items such as “is often absent-minded during his/her daily activities” or “often talks excessively”. Nobody explains us what is meant by “often” or “excessively”. If five symptoms are present, a diagnosis is not given; if they are six, the child is diagnosed. Therefore, what makes these behaviors a disease is not the inner characteristic of the symptom, or the quality of the interaction with the adults, but rather their numerousness, up the number of six. We are dealing with a decision by the DSM experts committee, which arbitrary sets the levels over which inattention, hyperactivity and impulsivity become a pathology. Many observers have doubted the soundness of such a totally subjective approach [8][9]. The main problem rises from the facts that these behaviors probably derive from several causes, and they can especially constitute normal temperamental variations. What makes them clinically relevant, therefore, is not necessarily their number, but rather a negative interaction of whichever of them with the expectations and answers from the living environment. Bad interaction and bad adaptation between these two elements is what amplifies the behavioral problem, making it dysfunctional. The great body of research concerning infantile disposition and its clinical significance brings an enormous amount of implications that have not been taken into any consideration by the DSM diagnostic system. Works by Chess and Thomas [10] and by many other authors among whom Carey and McDevitt [11], have demonstrated that although, on one hand, a pathology in the environment, in the child or both, can be responsible for the child’s dysfunctions, on the other hand there are many cases of pathogen sources that rather derive from a maladjusted interaction between a normal kid and a normal environment, yet incompatible with the child.

Every human being presents genetically predefined temperamental traits, which have been described as activity level, regularity in biological rhythms, withdrawal from, and approach to new situations, adaptability, intensity of emotional reactions, prevalent mood, attention threshold, distractibility, sensory attention threshold. In the overall population, these nine traits vary from “low” to “high”: from high to low activity levels, from high to low adaptability, and so forth. These variations are, in themselves, normal. Therefore, half the population is more active than the other half, half the population is less attentive than the other half, without this implying an abnormality [12].

Yet, some temperamental traits can imply bad adaptability to, and bad interaction with adults’ values and expectations. A “difficult” attitude, defined by low adaptability, negative mood, high emotional intensity, can lead the child to develop social behavioral problems, as already demonstrated by Thomas, Chess and Birch in 1968 [13], and by many others afterwards. A “low task-oriented” temperamental trait, characterized by high activity levels, low attention, high distractibility, can instead cause the child poor scholastic results, as demonstrated by Keogh and Martin [14][15]. Moreover, any temperamental trait can be a potential risk factor within a contrasting environment; for instance, in the case of a “low-active” child from a family of athletes and sportsmen who expect an active son.

Even when extreme, and exposing the child to the risk of social or scholastic dysfunctions, these temperamental traits do not, nevertheless, necessarily turn into health problems. “Difficult” kids can be behaviorally adequate if the family and the environment are sufficiently capable of accepting and supporting them [16]. Children with “low task-oriented” traits can obtain satisfying scholastic results if the family is supportive and if they present good intellectual abilities [17]. A longitudinal study demonstrated that only half the children who present extreme levels of hyperactivity, lack of attention and high distractibility reports scholastic problems; the other half obtains sufficient or good scholastic results [11]. What appears to be significant for the triggering of the child’s dysfunction is not the number of far-from-average temperamental traits, but, rather, whether there is or there is not good or bad adaptability (“fit”), a good or bad interaction between these traits and the requests from one particular living environment.

Another problem contributing to the insufficient clarity of the DSM diagnostic criteria is, undoubtedly, the study of the adopted methods. The diagnostic investigation is in fact based on clinical, self-selected population samples. If we examine high activity and low attention only within clinical samples, we cannot asset the frequency with which these traits appear in normal children also. A comparison between 40 children addressed to a specialist due to strongly hyperactive behaviors, and 30 control children equally hyperactive but not referred to a doctor, showed that “the best predictors of clinical referral were a parent’s ability to cope with child behavior, child emotional disturbance, school relationship problems, and parental disciplinary indulgence” [18]. Longitudinal studies showed that these children, normally functioning with hyperactivity and lack of attention, are not undiagnosed ADHD but, substantially, ordinary kids [19].

Summarizing, the current diagnostic formulation of ADHD, which subordinates the diagnosis to a certain number of behavioral expressions, ignores the fact that these behaviors are fundamentally normal temperamental traits, which can imply a maladjustment not because of their number, but rather because each of them can provoke a dysfunctional interaction between the child and an environment that contrasts him/her.

ADHD symptoms: a cerebral dysfunction?

Although the DSM-IV would not say so, every text and article on the subject takes for granted that hyperactive and inattentive behaviors are mostly caused by a cerebral dysfunction. This way, it is said that ADHD is currently recognized as a common neurobehavioral disease in children [20]. The most plausible explanation for such an assumption may date back to the ancient origins of the concept of ADHD, referring to now obsolete terms like “minimal brain damage” and “minimal brain dysfunction”. These definitions were abandoned in favor of the term ADHD, in order not to explicitly refer to any brain damage or dysfunction; yet, an implicit assumption of a damage remains in the minds of those who utilize the new definition. Which data support this implicit presumption? Some preliminary neuroimaging studies showed no significant difference between children with ADHD and other kids. Later studies conclude that the frontostriatal circuits can be involved in the ADHD [21].

On the contrary, several evidence deny the alleged neurological foundation of ADHD.

Today we know that several factors injurious to the brain, such as lead poisoning, fetal alcohol syndrome, low birth weight, cerebral traumas can lead to hyperactivity and lack of attention [22]. It is equally demonstrated that proven cerebral damages do not necessarily imply hyperactivity and lack of attention [23,24].

No particular neurological indicator, neither structural nor functional or chemical, was found in children with ADHD [25,26]. When reported, observations regarding this issue are always quite obscure: they do not report those aspects of the syndrome, to which they would be correlated; they do not specify their cause-effect relations, or at least their simple associations; they do not clarify whether they refer to congenital aspects or to traits that were acquired after birth.

On the other hand, it is proved that healthy children with normal temperamental variations present different cerebral functions. Within a sample of 48 four-year-old children, studied through electroencephalography, the ones who showed better social competencies presented a higher frontal left activation, while kids with high levels of social avoidance showed a stronger frontal right activation [27]. If studies demonstrated neurological differences in children with ADHD, they should also prove that the findings are connected to ADHD and not to other factors such as social or scholarly incompetence, temperamental differences and so forth. The sample population and the control population would require a more accurate selection, compared to what proposed by several researches.

Evidence for a genetic foundation of the ADHD syndrome [28] do not depose in favor of a cerebral anomaly in itself. Data suggest that ADHD behaviors vary genetically, on a continuum, among the overall population, instead of demonstrating a disease with discontinuous variations [9]. On the other hand, strong is the evidence of an important genetic effect on the temperamental variations [29], and of the problem solving strategies [30], with or without social and scholarly difficulties.

It is amazing to see how the prejudice in favor of the neurological foundation of ADHD is so strong and persistent, even in the absence of evidence. On the contrary, it is evident that in the USA there exist powerful social reasons needing parents and educators to think that the ADHD symptoms must be imputed to a deficient nervous system: for parents, guilt feelings and avoidance of educational responsibilities; for schools, the difficulties of implementing a flexible and adaptive system; for medicine, the need to defend its role. These factors are well described in details by Diller and Reid [31-32].

Summarizing, regardless of the accurate efforts of talented researches, the case of ADHD lacks any evidence of pathological cerebral alterations. If these behaviors are simple variations of a normal behavior, it will still be difficult, in the future, to demonstrate this cerebral pathology.

Are environmental and interactive factors being ignored?

After the progressive decline, from the 1950s onwards, of the environmental psychological theory (always blame everything on the mom), nowadays the majority of scholars leans towards an interactionist theory, according to which there is no predominance of nature or culture, while they are rather strictly interconnected, from conception to the end of life. Nevertheless, the DSM-IV ADHD criteria describe behaviors as something intrinsic in a child, and familiar or scholarly difficulties as characteristic of the child in him/herself. The quality of the environment, and the interactions between the environment and the child, are not taken into consideration. The prejudice, according to which the problem derives entirely from the deficient brain of the child, has scotomized the evaluation of the educational cures he/she receives. This prejudice impeded any progress in the comprehension of the meanings of the child’s behavior, and in the identification of alternative ways to help a certain child in a particular context.

Today, the body of the research on temperament, collected in the past thirty years, proves that clinical evolution is conditioned not only by the child’s inborn temperamental predispositions, but also by the way these factors interact with the living context. The evolution of children with a “difficult” temperament depends on how the child’s parents and significant adults provide answers that are “holding”, or conflictive and adversative to the child [33-34]. A group of Puerto Rican children in New York were considered normal and adequate by their parents, until the moment they entered the public scholarly system.

Levine [35] finds that the scholarly performances of low task-oriented children is mostly determined by the educational qualities of parents and teachers. Unfortunately, only few researchers studied the effect of the environment on ADHD. Some tried to understand the way that social difficulties, deriving from a premature institutionalization, combine with an inattentive and impulsive behavior [36].

Taylor [37] demonstrated that negative primary emotional relationships are strongly associated with an hyperactive behavior; Biederman and his colleagues [38] proved that chronic conflicts, reduced familiar cohesion, familiar psychopathology, maternal psychopathology are more frequent in families presenting cases of ADHD than in control families; Scahill and his colleagues [39] relate psychosocial stress to severe forms of ADHD. In any case, the typology of educational environment strongly determines whether to resort to a therapeutic intervention in case of an ADHD diagnosis.

Summarizing, for what concerns ADHD as well as the other forms of emotional and behavioral maladjustment, there are strong evidence of a large environmental influence on the long-term evolution of the children’s destinies.

Are diagnostic questionnaires valid?

It is not easy to present an exhaustive review of the several ways how, nowadays, doctors, psychologists and teachers reach an ADHD diagnosis. The DSM-IV only describes the diagnostic criteria, reports that at the moment there are no reliable physiological diagnostic or laboratory tests, and leaves the discretion about the instruments to use to the professionals. Considered such premises, it is obvious that the majority of operators chooses the simplest and most available methods. Usually, the majority of family doctors and pediatricians either starts from an informal interview guided by the DSM-IV criteria [40]; or uses one of the questionnaires designed to this end. The most renowned are the questionnaires by Conners: “Parent Rating Scale-Revised” for parents and “Teacher Rating Scale-Revised” for teachers, also available in an abbreviated form, and compilable in a few minutes. According to several authors [41-42], this is the modality that is most frequently adopted. Regardless of their great diffusion, these scales and their standardization on different populations raise many and important methodological problems. They do not fulfill the basic psychometric criteria completely. The items defining a condition are few in number. Every item is defined, as we already pointed out, in non-operational and highly subjective terms (“speaks excessively”, “is restless” and so forth). The compiler has no criteria to understand what “too much”, “often” and similar expressions mean. The answer, which must assign a frequency to a behavior choosing between “sometimes” and “often”, provides no indicators of reference. The questionnaire, therefore, assigns to the compiler the total responsibility of deciding non only if a behavior is present or not, but also, when present, if such behavior is normal or excessive. The questionnaire assumes the compiler’s answer to be objective. The differences in the parent’s or teacher’s experience, tolerance, emotional state, or other qualities are not considered at all. These questionnaires can be a measure for the parent’s or teacher’s unease, rather than for the child’s disability. And regardless of such kind of vagueness, the scale supporters expect them to provide an accurate yes-no diagnosis of the ADHD syndrome.

But the psychometric insufficiencies of the scale lead to some unpleasant consequences. The correlation between the different types of scales, utilized to this end, is very low [43], the consistency between distinct adults who evaluate the same child is very low, the comorbidity issue is not assessed. Such lack of precision in the scales led to the development of different new, and not yet validated, techniques, like the continuous performance test with EEC [44]. Reid and Maag [45] conclude by stating that since the evaluation scales claim to be objective, professionals can derive a secure ADHD diagnosis from their scores. But since the diagnosis obtained through a scale can be as accurate as a head or tails toss, scales can not in any way substitute an informed evaluation by a professional.

Summarizing, the scales currently in use for the diagnosis of ADHD are subjective and impressionistic, represent nothing but the teachers’ and parents’ perception and unease, cannot substitute a clinical interview and the direct observation, nor orient toward a diagnosis of cerebral dysfunction.

What is the weight of adaptability and of cognitive problems?

The DSM-IV definition states that inattentive and impulsive/hyperactive traits must imply one dysfunction in at least two life contexts (for instance, family and school). The DSM-IV also mentions a wide range of possible “associated diseases and characteristics”. Among these we find: low tolerance to frustration, bursts of rage, bullying, mood lability, dysphoria, low self-esteem, rejection of peers. Despite this long list of issues, the DMS-IV assumes ADHD to be a disease in itself, and not a predisposition towards other problems.

On the contrary, there is always more evidence of children presenting scholarly and behavioral problems, imputed to ADHD, and suffering from factors that determine their diseases and are different from inattention and hyperactivity. Data suggest a presence of typical cognitive disabilities in the different behavioral traits. Behavioral predispositions have been described in various ways but, in general, they are centered on the low adaptability and low flexibility dimensions. In a preliminary study from 1979 [46], 30 out of 61 children, sent by their teachers to an infantile neuropsychiatrist for behavioral and learning problems, received a diagnosis of MBD (minimal brain dysfunction); according to their parents’ Behavioral Stile Questionnaire, these children were actually more active and less attentive than the other 31, but the trait that would differentiate them the most was a low adaptability. While standardizing a new questionnaire for teachers of preschool children, Billman and McDevitt [47] find a 0.80 correlation between the items of impulsiveness-hyperactivity and those defining a low adaptability. Other authors reach complementary conclusions regarding the low-adaptability centrality, underlying the limited capability of modifying the behavior in accordance to the context requests and needs [48], the centrality of the way the children adjusts his/her reactions [37], and some incapability of self-control [49]. How come did the DSM experts neglect this important behavioral dimension? Probably, because of their low familiarity with the cognitive legacy of adaptability for what concerns social and scholarly adjustment. Or the confusion may derive from the fact that, usually, high and low adaptability are positively correlated in the Behavioral Style Questionnaire [50], as well as low persistence and low attention are positively correlated to low adaptability [51]. Nevertheless, low adaptability is an autonomous dimension, more powerful than the others in predicting scholarly and social adjustment. Cognitive disabilities is another factor which is highly involved in scholarly and behavioral problems, and which is not considered in case of ADHD. Levine [52] described in details the heterogeneity of associated displays and dysfunctions encountered in children with difficulties in attention, interfering with direct attention to the task during the scholarly years. Denckla [53] identifies the processes of cognitive planning, and of working memory among them. If these factors are not systematically investigated, the ADHD diagnosis can be incorrect.

In this perspective, inattention and hyperactivity can be a consequence, and not a cause, of more powerful risk factors, such as low adaptability and cognitive disabilities.

Does the diagnosis consider the evolutive perspective?

As we saw, the DSM-IV prejudice consists in supposing that the hyperactive and scholarly inattentive child has something wrong inside his/her brain. And this prejudice cannot avoid taking into consideration another aspect, that is, the fact that, as Carey and Devitt point out, our bodies and our minds, which have been evolving through millennia of hunting and harvesting in the African savannas, may sometimes not have evolved over the stone age in order to adapt to a highly artificial environment, such as modern school. In the end, the authors continue, short attention times and hyperactivity could have been highly appropriate for our ancestors, in order to favor survival in a world full of predators [11].

The modern school was established only 400 years ago; public school for everyone only 100 years ago: the rapid reaction times that were adaptive in the jungle world may have become less adaptive in relation to the useful behavior within an industrial and always more organized society [54]. In the light of these considerations, the presumption that the hyperactive and short-term attentive subject’s brain could be diseased appears little plausible.

Is the diagnosis useful or damaging to the kid?

Many authors underline the gratitude felt by people who received an ADHD diagnosis for their children or themselves. Many believe that this is a good mental health practice, since it relieves individuals and educators from the many guilty feelings about having caused their children’s problems. Labeling the child confirms the parents’ opinion that the child functions differently, and that the behavioral problems are not related to themselves. The ADHD diagnosis also allows the school to consider the child as a source of its problems, and to obtains funds for the special classes resources. The certification of a medical disease facilitates the use of drugs like the methylphenidate, which would be far less justifiable in case of a bad adaptation between the child, on one side, and the educators on the other.

Anyway, the negative aspects of a diagnostic label cannot be ignored:

This diagnosis has a limited practical value for teachers, psychologists and doctors, since it does not explicate the problems and the resources of that particular child. It does not contain information on the specific cognitive abilities and deficits of the children, nor it provides indication for the parents’ and teachers’ intervention areas. The complex phenomenon of attention is coded in a form that is too simplistic to offer a clinical use. Motivations and behavioral adaptations are not analyzed separately.

The management of the problem is invalidated by the fact that relatives and parents are excluded a priori from any responsibility, and all this occurs together with the presumption that the drug is the only practical form of treatment. Without considering the environmental influences on the child’s behavior, any possible positive intervention on the problem is given up from the beginning. No interaction between the infantile temperament and the adults’ educational attitude is taken into consideration. Reid [55] states that teachers, being part of the child’s environment, are surely also part of the problem and of its possible solution. On the other hand, the always growing resources offered to children who receive this diagnosis are subtracting any measure of intervention from children in educational difficulties and without such diagnosis; or may lead the operators to inappropriately extend this diagnosis.

In the long run, this diagnosis can prove to be stigmatizing and damaging, in a measure that is presently yet unforeseeable. The cerebral dysfunction label, apparently useful to the child today, can be harmful tomorrow in relation to employment, military service, the insurance system, the acquisition of licenses of various kinds.

The heterogeneous nature of the groups today identified with the ADHD diagnosis actually prevents any scientific progress, since it opposes to investigating the different etiologies and the different mechanisms that are subjected to this symptom, to following the different stories longitudinally, and to the confrontation between experts belonging to different approaches (see [20]

Are there bad practices in diagnosis and treatment?

Agreeing or not with the ADHD DSM criteria, it is evident that, on a practical level, these criteria are not applied rigorously in the majority of cases. Two recent studies, the first performed on over 400 American pediatricians [41], the second on general practitioners and pediatricians from North Carolina [43], demonstrated that the DSM diagnostic criteria were used in less than half of the cases receiving the diagnosis and the treatment with stimulants.

Another study found a dramatic increase in the prescription of these psychotropic drugs to children only two of age [56].

Many public operators keep thinking that, if the stimulant leads to an improvement in the child’s behavior, this is an indirect proof of the ADHD diagnosis and a good reason to proceed with the treatment. What these operators neglect is that every cerebral stimulant, including caffeine, reach the goal of improving the performances, especially cognitive, of every subject, including the so-called normal children [57-58-59].

Therefore, the large diffusion of Ritalin as an ex juvantibus proof is totally irrational (Diller, 1998). Moreover, even if the methylphenidate has certainly demonstrated its efficacy in many cases, yet its effects, when compared with a well-conducted psychological intervention, are overestimated [60].

Ethical aspects(**)

Comparing medicine and psychiatric practices

The principles exposed in the section “Scientific aspects” in relation to the definition and cataloging of diseases cannot be fully applied within the psychiatric field: several authors have, in fact, strongly opposed the validity of the expression “mental disease” [61].

It is worth remembering that psychiatry is still torn from within by many tendencies of thought (biological, psychological, social, bio-psycho-social or eclectic, and so forth), and that the biological approach, which, for instance, is established in the USA, is only one among the many [62].

The supporters of biological psychiatry tend, therefore, to demonstrate that mental diseases are “organic diseases”, just like all the others.

Nevertheless, to this aim, some unequivocal scientific proofs would be necessary, at least; yet, these are normally not available in psychiatry for any mental disease, also because, if biological proofs were to be outlined, a possible nosological entity of reference would fall under the domain of neurology, being an organic alteration of the central nervous system. Hence polemics are frequent, in literature, between neurologists and a certain kind of psychiatry.

In order to simplify our exposition, we will use as an example a typical psychiatric nosological entity: schizophrenia.

Regardless of the dozen thousands of autopsies performed on subjects suffering from schizophrenia, no specific pathological alteration has ever been detected.

The schizophrenia diagnosis is solely based on symptoms, i.e., on what the patient does or says. Signs independent from subjectivity do not exist. A confirmation of this statement (as if it was needed, against any evidence) comes from many large-scaled experiments that have been conducted in the past (see, for instance, the experiment by Rosenhan (63).

The instrumental exams utilized so far, including the most sophisticated available (NMR, Spect, Pet and so forth), have not demonstrated any variation, neither anatomical nor functional, between the central nervous system of a subject defined as a schizophrenic, and a subject defined normal or healthy.

Of course, this does not mean that schizophrenia does not exist as a disease, but it simply invites us to ponder the organic origin of the disease itself. In his book “Insanity”, the psychiatrist and professor Thomas Szasz [64] provides us with a further incentive to reflection. Within medicine, we can encounter the following situations:

Signs

Symptoms

Condition

-

-

Healthy

+

+

Diseased

+

-

Asymptomatic diseased

-

+

Hypochondriac, simulator or indeterminably diseased

This clear exemplification cannot function when transferred onto the psychiatric field; for instance, in the third category, it would create the case of the asymptomatic diseased person, i.e. an asymptomatic schizophrenic, that is, in facts, an oxymoron.

It is obvious that, in the face of such situation which is gravid of evident contradictions, some psychiatric approaches have been trying for centuries to overcome the obstacle, seeking to credit psychiatry as a biologic science. Always according to the historical context of the time, these attempts produced the hypotheses of the “schizococcus”, the virus, the genetic alteration and, more recently, of the biochemical neurotransmitters unbalance, which is, too, under discussion by the medical community. Hypotheses which were lately proven false and which actually remain mere hypotheses; yet, they were valiantly defended by some insiders, psychiatrists or not, with the exact identical approach that is nowadays adopted for the ADHD phenomenon. Again, this does not mean that ADHD does not exists, but certainly suggests the maximum prudence.

Many current assumptions of clinical relevance, solely based on correlation factors, move towards this very direction. This is an even more ambitious attempt, that is, to identify the cause or rather the etiology. Even if such step is actually unnecessary for accrediting a biologic theory on a pathology (we do not know the causes of cancer, as well as of many more organic diseases, but nobody can deny that these are organic, given the evidence of anatomic-pathologic and clinical-instrumental signs and confirmations), it is worth examining some correlation factors that are used in psychiatry on this topic.

The DSM (Diagnostic and Statistical Manual of mental disorders) and its relation with ADHD (Attention-Deficit/Hyperactivity Disorder)

The DSM manual was created with the aim to guarantee a common language an more uniformity of diagnostic criteria in the psychiatric field, within the different nations and geographic areas.

This aim was a good reason, but, in time, the situation has substantially changed.

Along the years, the DSM was progressively enlarged with the addition of many new psychiatric “pathologies”. Every new listed nosological entity is established trough the discussion and voting of a group of experts. This is certainly a democratic criterion, as much as it is certainly not scientific.

Within medicine, we will never be able to assess, through a decision, whether cholera is a disease or not: this depends on proofs and incontrovertible facts. Within psychiatry, homosexuality and masturbation have been long considered pathologies, while they are not anymore; gambling has always been considered a problem of moral nature, now they tell us it is a disease.

As the years went by, the DSM compilers realized that they could extend their influence and their interests over a practically unlimited quantity of human attitudes or problems.

Some more critical observers recall the historical origins of this particular psychiatric approach, which, as we will see, must be directly confronted with some aspects of the ADHD phenomenon of our interest.

In 1940, psychiatrist J.R. Rees declared in his “Strategic planning for mental health” [65]: “If we are to infiltrate the professional and social activities of other people I think we must imitate the Totalitarian and organise some kind of fifth column activity! (…) We have made a useful attack upon a number of professions. The two easiest of them naturally are the teaching profession and the Church: the two most difficult are law and medicine. (…) Don’t let us mention Mental Hygiene, (…), though we can safely write in terms of mental health. (…) Let us all, therefore, very secretly be fifth columnists“.

A few years later, in 1946, the Canadian psychiatrist Brock Chisholm, founder of the World Federation for Mental Health, one of the top world psychiatric institutions, wrote: “…it would be more advantageous to the world for psychiatrists to go into the preventive field where the big job needs to be done. (…)The re-interpretation and eventually eradication of the concept of right and wrong (…), these are the belated objectives of practically all effective psychotherapy. (…) If the race is to be freed from its crippling burden of good and evil it must be psychiatrists who take the original responsibility [66].”

The idea of psychiatry leading the destiny of the world, proceeding through the selection of the best human race, had thus already been spreading for many years.

Eugenics, the fundamental inspiring principle for Nazis, developed far before Nazism and did not cease to be, together with it. Undoubtedly, the most influential and important scientist of the Nazi era was doctor Ernst Rudin, who had founded in 1905 the “German Society for Racial Hygiene”, together with his brother in law, psychiatrist Alfred Ploetzl [67]. Having being elected president of the “International Federation of Eugenics Organizations” and of the “Committee on Race Psychiatry” in 1932 [68], after Hitler’s rise to power in 1933 Rudin started the program, coordinated by Heinrich Himmler, for the elimination of 375.000 German citizens considered “inferior”, a program that preceded the Holocaust [69].

During the Nuremberg trials, only the doctors who were specifically working in the concentration camps where under accusation; and not even all of them. Apart from a few others who were identified many years later, like psychiatrists Heyde and Lotte, all the ideological brains of eugenics were and kept being free of operating and, most importantly, to teach [70]. Rudin, as a Swiss citizen, was condemned to a short period of house arrest and died in 1952 [71].

Going back from history – yet a recent history – to the chronicle of our years, the 1994 edition of the renown “Comprehensive Textbook of Psychiatry” celebrated Rudin as the “father” of theories on the genetic origins of schizophrenia. In 1990, the National Alliance for Research on Schizophrenia and Depression published an article where Rudin was thanked (!) for his pioneering work in the field of genetic psychiatry [72].

The scholar and successor of Rudin at the Kaiser Wilhelm Institute, dr. Frank J. Kallmann, relocated his own chair at the New York State Psychiatric Institute [NYSPI] of Columbia University, were he became in charge of the genetic psychiatry programs [73]. After the Holocaust, Kallman in person witnessed in favor of Otmar Von Verschuer, one of the psychiatrists who personally selected the individuals to be killed in the course of the extermination. Helped by a part of the psychiatric community of the time, Von Verschuer was sanctioned with a fee of only 300 dollars, and was released [74].

Both of them collaborated, in the 1950s, to the US program of “Negative eugenics”, aimed at suppressing the reproduction of “inferior” individuals [75]. Kallman worked for a long time with dr. Linda Erlenmeyer-Kimling, an expert on genetics, again at the NYSPI.

Erlenmeyer-Kimling, together with Kallman, is the author of the first studies on the necessity of precociously identify mental illnesses since early childhood. The precocious identification of children, as carriers of madness genes, was also the main goal of Ernst Rudin’s work.

In 1971 the American Eugenics Society changed its name, becoming the American Social Biology Society [76]: “social biology” was the term used by Nazi Ernst Rudin to define his school of thought. Starting from the 1970s and 80s, the works by Erlenmeyer-Kimling are the funding bases for the screening programs that aim at identifying signs of “mental diseases” in children [77].

All that is written in this section are objective historical reports, undeniable and outlined in the present contest without being accompanied by any trial on their merits.

The cure for ADHD: an obligation of ethic nature or a “good deal”?

The treatment for ADHD (Attention-Deficit/Hyperactivity Disorder) currently in use mainly consists of the administration of a psychotropic drug, the methylphenidate (during the 1970s, a fashionable amphetamine among some US western communities of drug addicts– but there are other specific drugs just about to enter the market); from the educational point of view, the kid is “trained” to solve his/her problems (given that they actually exist) with a pill. The methylphenidate, which is distributed in massive doses by now, even led to drug-dealing episodes. Cases of children from poor families, who are trained by their parents to be restless in school, in order to obtain the diagnosis and the drug, are not infrequent and also reported by press organs; the drug is then sold on the streets at high prices, becoming an interesting source of profit [78]. About side effects of methylphenidate at the cerebral level, we simply suggest the reading of a recent publication called “Ritalin e Cervello” (Ritalin and the Brain) by dr. Heinrich Kremer, professor of toxicology and social medicine, published in Italy by Macro Editions (February 2002).

In the USA, the diagnosis is fundamentally uttered by teachers through the utilization of the aforementioned tests. Therefore, the training and persuasion of the teaching staff is essential, which would introduce even further perplexity, if more perplexity was needed…

The polemics on ADHD, which is also the original reason for our campaign, started in fact in the USA. When a certain kind of health intervention is strongly propagandized, those who refuse to “have their children cured” can be charged with lack of medical assistance (negligence) and custody rights can be denied. In the USA there are many legal suits of this kind, one even regarding the brother of a US President, who refused to have his son “cured” [79]. As we mentioned at the beginning of our review, after uncountable other laws at national level [80], some time ago the US Parliament has approved (with 425 votes in favor, and one against) a law which will prevent the parents of children labeled as suffering from ADHD from having to accept any therapy or treatment they do not agree with [81].

A first consideration on these data regards the voting outcomes; a second consideration outlines how the issue is conceived by the USA representatives, almost unanimously, (and therefore, by all of their technical-scientific consultants), as a topic unproven by medical or scientific bases. As we know, no State has ever approved a similar legislative instrument concerning cholera, infantile leukemia, muscular dystrophy or any other pathology.

Of course, by redefining the human behaviors and labeling them as pathologies, anything can become a serious and widespread disease, given three conditions:

To have the financial means needed to propagandize this idea;

To hold some sort of doctrinal authority, in order to impose the idea under the entry “scientific data”;

Possibly, to rely on sufficiently ignorant or simpleton interlocutors.

In the past, we witnessed extremely steady and resolute opinions, grandiloquent and repeated with tremendous outcry, on the alleged and consolidated scientific validation of ADHD. Some even quoted the number of scientific publications, or more simply tried to insult and denigrate those who were contesting such validation. However, in science the onus probandi lies solely on those who propose a new or a different postulate. Since in reality, so far, none of the thousands scientific publications on ADHD has proved a thing, it would be useless even to reply, as much as we do not consider it useful to reply (up to now) to those who affirm the existence of aliens on earth, or of witches.

We believe it would be appropriate to lower the tones of the polemics, drawing again science closer to the characteristics of modesty and prudence that should belong to any professional deserving such title.

The alarm uttered by many associations and bodies, at national and international levels, derives solely from the observation of the following facts:

- Almost 11 million children are labeled, and undergo psycho-pharmaceutical treatments in the USA alone;

- Almost 200 documented deaths are related to the treatment [82];

- An enormous business turnover is sustaining the market.

Since, as we saw, a true counter-tendency in the administration of psychotropic drugs to children and teenagers is taking place in the USA, some critical sources denounce how an enormous effort is being addressed to find ADHD supporters in nations considered “secondary”, in order to balance what is starting signaling a sagging in the American market; Italy is certainly among them. Therefore – a case rare to the point of being unique, and causing several doubts – in October 2000 the Italian Joint Commission on Drugs, or CUF, has “urged” the pharmaceutical company producing methylphenidate to “activate”, in order to start the drug’s registration procedures on the Italian market [83]. Furthermore, the legislative bills that are currently under examination by the Social Affair Commission of the Chamber of Deputies, regarding mental health, contain specific articles to activate a mass children screening within schools, and to “train” the teachers to this aim [84].

Of course, this is explained to citizens and even to politicians as a necessity to help children and families, allowing to precociously identify any behavioral alteration.

A democratic and liberal State should be “at the citizen’s service”, acting on his/her behalf and not arranging a “cataloging” of citizens, which has, moreover, already taken places in at least two historical occasions (in Nazi Germany and communist Russia).

Why then, not to impose some blood tests as mandatory, in order to identify every carrier of some diseases? To answer this question, we must first ask another: are the citizens in control of the State, or is the State controlling the citizens?

Browsing these names, it is natural to wonder how some of them could, with such a “deficit”, provide a contribution of inestimable cultural value to humanity.

Doctor Paul Elliot has stated:

“The average I.Q. of the person with ADD is higher than that of the average person in society.

[…] The person with ADD has a greater ability to think creatively. This refers not only to creativity in the fine arts sense, though a person may have such a musical or painting talent, but to the ability to problem solve, create, or invent. The person with the ADD brain structure has an increased sensory awareness. This stems not only from a heightened sensitivity of the senses, but also from the increased intrusion of those sensations into the conscious awareness of the person. In other words, the person sees, feels, hears, tastes, and smells more, and these sensations are more likely to distract the person. Finally, the higher one goes on the I.Q. scale, the greater the percentage of ADD one finds. From an I.Q. of about 160 and above, virtually everyone has ADD. Now, if that is “brain damage,” as was previously felt, we should all be so damaged! Certainly it is not brain damage, and the sooner we acknowledge this, the sooner we will be able to take a more appropriate approach to ADD.”

Both the Food and Drug Administration (FDA) and the Drug Enforcement Administration (DEA), respectively the USA Ministry of Health and the Narcotics Department, declared that these supposed-to-be pathologies do not present any known biological causes.

In a document dated December 1999 and regarding the simulation of brain therapies long-term effects, the NIMH (National Institute of Mental Health) declares that stimulants suppress the symptoms of the ADHD syndrome, but do not cure it in itself. As a result, children suffering from ADHD must often be treated with other psychotropic drugs for many years following the therapy.

Therefore, not only it does not appear to be a therapy, but it also does not improve the children’s scholarly results.

Many psychotropic drugs that are administered to children are “off-label”, i.e. designed and conceived for adults, and nothing is known about the real effects on children. Nevertheless, the neuro-biological origin still reigns, with unshakable certainty, among some psychiatrists.

Moreover, one hundred years of psychiatric observations accustomed us to the transitory nature of many mental diseases: this does not mean that they “come and go” throughout an individual’s life, but that they manifest themselves in a specific time and place, mysteriously disappearing afterwards.

The controversial pharmacological therapy.

These psychotropic drugs (for instance the methylphenidate, a strong stimulant) have been on the American market for almost half a century; they represent a lifestyle to many, and still have their admirers.

In his article “Sorry, but your soul just died”, Tom Wolfe wrote:

“Nevertheless, all across America we have the spectacle of an entire generation of little boys, by the tens of thousands, being dosed up on ADD’s magic bullet of choice, Ritalin, the CIBA–Geneva Corporation’s brand name for the stimulant methylphenidate. I first encountered Ritalin in 1966 when I was in San Francisco doing research for a book on the psychedelic or hippie movement. You’d see them in the throes of absolute Ritalin raptures… Not a wiggle, not a peep… They would sit engrossed in anything at all… a manhole cover, their own palm wrinkles… indefinitely… through shoulda–been mealtime after mealtime… through raging insomnias… Pure methylphenidate nirvana… From 1990 to 1995, CIBA–Geneva’s sales of Ritalin rose 600 percent; and not because of the appetites of subsets of the species Speed Freak in San Francisco, either. It was because an entire generation of American boys, from the best private schools of the Northeast to the worst sludge–trap public schools of Los Angeles and San Diego, was now strung out on methylphenidate, diligently doled out to them every day by their connection, the school nurse.”

Among American teenagers, methylphenidate is taken for “recreational” purposes: it is the most used drug by now, and DEA believes many death to have been caused by its abuse. In 1995, in Texas, the number of kids who resorted to an emergency room service for a Ritalin intoxication were as many as those who did it for cocaine, and 200 large-scale thefts of methylphenidate were reported, prevalently from drug stores. In its report dated October 20th, 1995, DEA states that the number of recourses to emergency rooms are growing year by year, and the documented cases of methylphenidate abuse are immensely more numerous than those of any other stimulant from its same pharmaceutical category.

In 1995, Newsweek wrote that methylphenidate is the favorite, easy to find and low cost drug within campuses, and that students do not consider it dangerous.

But what is the reason why this kind of legalized drugs has seen such a rapid mass diffusion?

In 1991, a directive from the U.S. Department of Education instructed the public school supervisors with guidelines for differentiated educational programs targeting scholars with ADHD. Therefore, every year schools receive hundreds of dollars for each student diagnosed with ADHD, and since these typologies of “reimburses” have been established, diagnoses have been increasing by 21% per year.

In Chicago, this psychotropic drug gets mixed with heroin and cocaine. In Detroit and Minneapolis/St. Paul, it gets pulverized and inhaled. The demand is so high that it is not always available for legal use. Researchers stress greatly its similarity with cocaine, but also with amphetamines. Methylphenidate users state that they feel “focused”, similarly to what happens with cocaine; the shift to this latter drug takes place with dosages that are higher than those of people who start using it without having previously being administered the stimulant.

In reality, little is known about the implicit mechanisms and the long-term effects on children, since only one single longitudinal study covered up to two years. All that can be said for now, is that methylphenidate works on adults like the similar other drugs. The International Olympic Committee forbids athletes to use methylphenidate, since it improves their performances artificially. The idea that this drug is immune to abuse is wrong: even children from primary school look for, and find, extra doses in addition to what prescribed.

The International Journal of Addictions lists over 100 adverse reactions caused by this drug. The drama lived by many parents is that teachers threaten to place their children in special classes, or to opt for domiciliary education if they do not take the drug. Increasing cases see judges subjecting children to a mandatory health treatment, forcing and coercing children to take the drug even in case of opposition by their parents.

Easy diagnoses

On September 27th, 2000, doctor David Fasser, as representative of the American Psychiatric Association (APA), American Academy of Child and Adolescent Psychiatry, declared to the American Parliamentary “Committee on the Education and the Workforce”:

“…Attention Deficit Hyperactivity Disorder, or ADHD, is the most commonly diagnosed psychiatric disorder of childhood. It’s estimated to affect between 3 and 5 percent of school-age children, and it occurs three times more often in boys than in girls. The Surgeon General’s recent conference cited the under-diagnosis and under treatment of mental disorders in children, particularly in African-American and other minority populations due to lack of access to medical services. […] Let me be very clear. ADHD is not an easy diagnosis to make, and it’s not a diagnosis that can be made in a 5 or 10 minute office visit. Many other problems, including anxiety disorders, depression and learning disabilities can present with signs and symptoms which look similar to ADHD. There is also a high degree of comorbidity, meaning that over half the kids who have ADHD also have a second significant psychiatric problem. […] In summary, let me emphasize that child psychiatric disorders, including ADHD, are diagnosable and real illnesses, and they affect lots of kids.”

On the other hand, two days later, the renown psychiatrist Peter Breggin was declaring to the same Committee:

“…The number of children on these drugs has continued to escalate. A recent study in Virginia indicated that up to 20% of white boys in the fifth grade were receiving stimulant drugs during the day from school officials. Another study from North Carolina showed that 10% of children were receiving stimulant drugs at home or in school. The rates for boys were not disclosed but probably exceeded 15%. With 53 million children enrolled in school, probably more than 5 million are taking stimulant drugs. […] Stimulant medications are far more dangerous than most practitioners and published experts seem to realize. I summarized many of these effects in my scientific presentation on the mechanism of action and adverse effects of stimulant drugs to the November 1998 NIH Consensus Development Conference on the Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder, and then published more detailed analyses in several scientific sources. […] Stimulants even more often become gateway drugs to additional psychiatric medications. Stimulant-induced over stimulation, for example, is often treated with addictive or dangerous sedatives, while stimulant-induced depression is often treated with dangerous, unapproved antidepressants. As the child’s emotional control breaks down due to medication effects, mood stabilizers may be added. Eventually, these children end up on four or five psychiatric drugs at once and a diagnosis of bipolar disorder by the age of eight or ten […] It is important for the Education Committee to understand that the ADD/ADHD diagnosis was developed specifically for the purpose of justifying the use of drugs to subdue the behaviors of children in the classroom. […]”.

According to Fred Baughman Jr. (a California-based pediatric neurologist, medical advisor for the Literacy Foundation and member of the American Academy of Neurology), the diagnosed children would represent 33% of the primary school population. In some classes, half of the scholars are on Ritalin: 10-15% of children, on a national level, would be at risk, and this diagnosis doubles every 4-5 years.

The International Narcotics Control Board report, issued on February 23rd, 1999, stated:

“Use of the stimulant, methylphenidate, to treat Attentional Deficit/Hyperactivity Disorder (ADHD) has risen by a staggering 100 per cent in more than 50 countries. In several nations — Australia, Belgium, Canada, Germany, Iceland, Ireland, the Netherlands, New Zealand, Norway, Spain and the United Kingdom — use of the drug could reach levels as high as in the United States, which currently consumes more than 85 per cent of the world total. The Board urges nations to seek out possible over-diagnosis of ADHD and curb excessive use of methylphenidate. Patients being treated with the drug, who were mainly primary school boys at the beginning of the 1990s, now include an increasing number of children, adolescents and adults. Children as young as one year are being diagnosed with ADHD in the United States.”

Again in the United States, the Attention Deficit Disorder (ADD) multiplied from 500.000 cases in 1988, to 4.400.000 in 1997, having today exceeded 6millions cases. The administration to the age group of 2-4 year-old is rapidly increasing: between 1991 and 1995, the use of Ritalin among American children in pre-scholar age has in fact increased by 150%, while the use of antidepressants such as Prozac raised as much as by 200%, as highlighted in an article by the American Medical Association, regardless of the overwhelming proves gathered on healthy volunteers, subjected to a treatment with selective serotonin reuptake inhibitors (SSRIs); tests that clarify how these drugs induce a significant rate of patients to suicide, suicide attempts, homicide, and create addiction (concerning this topic, see the relation written by doctor David Healy, one of the top world experts on SSRIs, for the Medicine Control Agency).

Methylphenidate is not, however, the only drug administered to children, and America is not the only country where it is promoted on a large scale. Dextroamphetamine, pemoline, methamphetamine and Adderall are also used. The commonly non-stimulant drugs, used on 20% of children and teenagers, who do not respond to the stimulant ones, for the presence of pathologies induced by the drugs themselves are: haloperidol, pimozide, clonidine, guanfacine, nortriptyline, amitriptyline, imipramine, deprenyl, clomipramine, desipramine, bupropion, fluoxetine, nicotine, MAOIs, moclobemide, carbamazepine, valproat, lithium, chlorpromazine, venlafaxine, buspirone, BZDs (source: A. Rossi, R. Pollice, Department of Experimental Medicine, Psychiatric Clinic of the University of L’Aquila, “Giornale italiano di psicopatatologia”).

The phenomenon regards the majority of the industrialized countries, and is worryingly increasing anywhere. In Australia, the dexamphetamine prescriptions increased from 9.937 in 1990, to 127.377 in 1995. The Ritalin prescriptions increased from 13.398 to 46.543 within 4 years. In England, 200.000 children are cured with drugs, with a trend to double every year; while in Canada, children addicted to psychotropic drugs are already over 1.500.000.

From 1980 onwards, the diagnostic criteria of the DSM (the psychiatric manual that lists every possible pathology, scientifically demonstrated or not) have progressively become more “elastic”, so much that the diagnosis is potentially extendible to the whole scholarly population. The symptomatic behaviors are described very generically, leaving such a degree of discretion to the observer that observations are made incomparable, and the construction of normative instruments mistaken: in practice, there exist no independent psycho-diagnostic instrument or medical analysis able to demonstrate with certainty the existence of many pathologies referred to childhood.

“… However, the diagnosis of ADHD remains challenging as the diagnostic criteria continue to have limitations. The diagnosis is dependent on reports of a child’ behaviors by multiple sources, particularly parents and teachers. However, there frequently are discrepancies between reports by parents and by teachers, with no clear method to handle these discrepancies. One source for the discrepancies is the fact that the behaviors are affected by the environment. Thus, the classroom setting may produce different behaviors from those seen at home. Further, the reports are somewhat subjective because there is no specific normative information for those each behavior. Observers must use their own judgment. In addition, the criteria are the same regardless of developmental age, but in reality, children’s behavior will vary depending on their developmental level.”

The differential diagnosis is particularly difficult, and diagnostic mistakes statistically exceed 50%. This problem was already outlined, in 1996, by a report of the “U.S. Department of Justice Drug Enforcement Administration”. In a pilot study conducted in Canada some years ago by dr. Wendy Roberts, director of the “Child Developement Centre at Sick Children’s Hospital in Toronto”, only two among 10 examined children, previously labeled, met the minimal diagnostic criteria that are characteristic of ADHD. The diagnosis is often uttered by general practitioners (35% of diagnoses in Canada), who have not enough competence or time to perform a differential diagnosis.

Conflicting interests

In the USA there are several open class actions (Texas, California, New Jersey) against psychotropic drugs abuse, involving the American Psychiatric Association (APA) and the association of patients CHADD over a collusion with the pharmaceutical company Novartis. According to the charges, the APA allegedly accepted money from Ciba-Geigy, and formulated ADHD diagnostic criteria that were progressively more “elastic” in every DSM edition, in order to favor the diagnosis and the sale of Ritalin and other psychotropic drugs.

“Children and Adults with Attention Deficit/Hyperactivity Disorder” (CHADD) is the most important support association for ADHD carriers, it boasts some of the best ADHD specialists among its staff, and rigorously supports the theory of the syndrome’s biological origin. Especially active on the web, it clarifies and answers to any doubt or attack to ADHD and Ritalin, at an impressive speed. Its representatives participate to conferences in American schools, asserting the indispensable necessity of the drug; they distribute informative brochures on ADHD to teachers and parents, often being these brochures the only source of information within schools; a careful reader will discover how the brochure is printed and edited by Novartis, the pharmaceutical company that produces the very drugs that are suggested as a cure. In 1995 Novartis launched a grand-styled campaign, asking DEA to shift Ritalin from Table II – a position that causes the control over the annual marketable quantities – and to insert it in Table III, for a problem-free fruition and sale-off, as often happens up to now. This petition was also subscribed by the Academy of Neurology and supported by the American Psychological Association and the American Academy of Child and Adolescent Psychiatry: an unprecedented defense for a drug belonging to Table II. Before DEA had the time to answer, a shocking TV documentary showed how CHADD had cashed no less than $900.000, within five years, from Ciba-Geigy, now Novartis, the pharmaceutical company producing Ritalin.

In its reply, DEA therefore pointed out how:

“the United Nations International Narcotics Control Board (INCB) had expressed concern about non-governmental organizations and parental associations in the United States that are actively lobbying for the medical use of methylphenidate for children with ADD.”

The “National Alliance for the Mental Health” (NAMI) is the biggest American association for relatives of persons suffering from psychiatric diseases. The magazine Mother Jones, in December 1999, published some NAMI’s confidential documents which seemed to prove the takings of over 110 million dollars from 18 pharmaceutical companies, from 1996 to 1999. As chance would have it, this association is particularly active in having laws approved, in various States, favoring involuntary psychiatric holds (the coercive hospitalization that goes against the subjects’ and even their relatives’ will) and the home delivery and administration of psychotropic drugs.

Fred Baughman Jr. asserts that, after five attempts, he did not manage to obtain from Ciba-Geigy, producing Ritalin, any reference to scientific works proving that ADD is a true disease. On November 17th, 1994, he wrote to David Kassler, a Food and Drug Administration (FDA) officer, asking why they would permit Ciba-Geigy to describe ADD as a “syndrome”, a term functioning as a synonym for “disease”. FDA answered admitting that a distinct patho-physiology of the disease was actually not delineated yet. Baughman concludes that FDA permits Ciba-Geigy to perpetrate the illusion of a disease, in order to sell massive quantities of psychotropic drugs.

The relation between the increment in diagnoses and the increase in the quantities allowed by the U.S. Drug Enforcement Agency (DEA), would therefore not be casual: from 1700 kg in 1990 to 8000 kg in 1995. To all this, we must add an efficiency cultural context and “psychological terrorism” from a certain psychiatry, asserting that children with ADHD tend to develop “any sort of syndromes”.

7. Final Statement of the Panel of the NIH, Consensus Conference on ADHD, November 18, 1998.

8. Achenbach TM, Howell CT, McCounaghy CH, Stanger C. Six year predictors of problems in a national sample of children and youth: cross-informant syndromes. J of American Academy of Child and Adolescent Psychiatry 1995;34:336-47

25. Peterson BS. Neuroimaging in child and adolescent neuropsychiatric disorders. J of American Academy of Child and Adolescent Psychiatry 1995;34:1560-76

26. Zametkin A, Ernst I, Silver R. Laboratory and diagnostic testing in child and adolescent psychiatry: a review of the past 10 years. J of American Academy of Child and Adolescent Psychiatry 1998;37:464-72

60. Carey WB. What the multimodal treatment study of children with attention deficit hyperactivity disorder did and did not say about the use of methylphenidate for attention deficits. Pediatrics 2000;105:863-4

83. In October 2000, the CUF invited the company producing methylphenidate to start the procedures for the registration on the Italian market. The drug is currently utilized in several centers for testing purposes, the treatment being administered to teenagers and also to children from the earliest youth.

84. See the new joint text of the Buriani-Procaccini parliamentary bill – consolidating act by the relator – March 2003, currently under discussion by the Social Affair Commission of the Chamber of Deputies, art. 14, tating that:a)For the precocious identification of the situations at psychopathologic risk and of psychiatric disorders, the Minister of Health, with its own decree, establishes the realization modalities of specific programs aiming at spreading appropriate and satisfying interventions within schools, starting from nursery schools. The programs must provide screening procedures and teachers training.

b) The Ministry of Health, with its own decree, establishes the realization of informative programs towards the population, with the aim of reducing and overcoming the prejudices on stigmatic prejudices; it also promotes training programs for general practitioners, in the field of mental health, and research programs for the precocious diagnosis.